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Lip and Oral Cavity Cancer Treatment

General Information About Lip and Oral Cavity Cancer

Anatomy

The oral cavity extends from the skin-vermilion junctions of the anterior lips to the junction of the hard and soft palates above and to the line of circumvallate papillae below and is divided into the following specific areas:

Lip.

Anterior two thirds of tongue.

Buccal mucosa.

Floor of mouth.

Lower gingiva.

Retromolar trigone.

Upper gingiva.

Hard palate.

Histopathology

The main routes of lymph node drainage are into the first station nodes (i.e., buccinator, jugulodigastric, submandibular, and submental). Sites close to the midline often drain bilaterally. Second station nodes include the parotid, jugular, and the upper and lower posterior cervical nodes.

Prognostic Factors

Early cancers (stage I and stage II) of the lip and oral cavity are highly curable by surgery or by radiation therapy, and the choice of treatment is dictated by the anticipated functional and cosmetic results of treatment and by the availability of the particular expertise required of the surgeon or radiation oncologist for the individual patient.[1,2,3] The presence of a positive margin or a tumor depth of more than 5 mm significantly increases the risk of local recurrence and suggests that combined modality treatment may be beneficial.[4,5]

Advanced cancers (stage III and stage IV) of the lip and oral cavity represent a wide spectrum of challenges for the surgeon and radiation oncologist. Except for patients with small T3 lesions and no regional lymph node and no distant metastases or who have no lymph nodes larger than 2 cm in diameter, for whom treatment by radiation therapy alone or surgery alone might be appropriate, most patients with stage III or stage IV tumors are candidates for treatment by a combination of surgery and radiation therapy.[2] Furthermore, because local recurrence and/or distant metastases are common in this group of patients, they should be considered for clinical trials. Such trials evaluate the potential role of radiation modifiers or combination chemotherapy combined with surgery and/or radiation therapy.

Survival

Patients with head and neck cancers have an increased chance of developing a second primary tumor of the upper aerodigestive tract.[6,7] A study has shown that daily treatment of these patients with moderate doses of isotretinoin (13-cis-retinoic acid) for 1 year can significantly reduce the incidence of second tumors. No survival advantage has yet been demonstrated, however, in part due to recurrence and death from the primary malignancy. An additional trial has shown no benefit of retinyl palmitate or retinyl palmitate plus beta-carotene when compared to retinoic acid alone.[8][Level of evidence: 1iiDii]

The rate of curability of cancers of the lip and oral cavity varies depending on the stage and specific site. Most patients present with early cancers of the lip, which are highly curable by surgery or by radiation therapy with cure rates of 90% to 100%. Small cancers of the retromolar trigone, hard palate, and upper gingiva are highly curable by either radiation therapy or surgery with survival rates of as much as 100%. Local control rates of as much as 90% can be achieved with either radiation therapy or surgery in small cancers of the anterior tongue, the floor of the mouth, and buccal mucosa.[9]

Moderately advanced and advanced cancers of the lip also can be controlled effectively by surgery or radiation therapy or a combination of these. The choice of treatment is generally dictated by the anticipated functional and cosmetic results of the treatment. Moderately advanced lesions of the retromolar trigone without evidence of spread to cervical lymph nodes are usually curable and have shown local control rates of as much as 90%; such lesions of the hard palate, upper gingiva, and buccal mucosa have a local control rate of as much as 80%. In the absence of clinical evidence of spread to cervical lymph nodes, moderately advanced lesions of the floor of the mouth and anterior tongue are generally curable with survival rates of as much as 70% and 65%, respectively.[9,10]

Related Summaries

Other PDQ summaries containing information related to lip and oral cavity cancer include the following:

Cellular Classification of Lip and Oral Cavity Cancer

Most head and neck cancers are of the squamous cell variety and may be preceded by various precancerous lesions. Minor salivary gland tumors are not uncommon in these sites. Specimens removed from the lesions may show the carcinomas to be noninvasive, in which case the term carcinoma in situ is applied. An invasive carcinoma will be well differentiated, moderately well-differentiated, poorly differentiated or undifferentiated.

No statistically significant correlation between degree of differentiation and the biologic behavior of the cancer exists; however, vascular invasion is a negative prognostic factor.[2]

Other tumors of glandular epithelium, odontogenic apparatus, lymphoid tissue, soft tissue, and bone and cartilage origin require special consideration and are not included in this section of PDQ. Reference to the World Health Organization nomenclature is recommended.

The term leukoplakia should be used only as a clinically descriptive term meaning that the observer sees a white patch that does not rub off, the significance of which depends on the histologic findings. Leukoplakia can range from hyperkeratosis to an actual early invasive carcinoma or may only represent a fungal infection, lichen planus, or other benign oral disease.

Stage Information for Lip and Oral Cavity Cancer

The staging systems are all clinical staging and are based on the best possible estimate of the extent of disease before treatment. The assessment of the primary tumor is based on inspection and palpation when possible and by both indirect mirror examination and direct endoscopy when necessary. The tumor must be confirmed histologically, and any other pathologic data obtained on biopsy may be included. The appropriate nodal drainage areas are examined by careful palpation. Information from diagnostic imaging studies may be used in staging. Magnetic resonance imaging offers an advantage over computed tomographic scans in the detection and localization of head and neck tumors and in the distinction of lymph nodes from blood vessels.[1] If a patient relapses, complete restaging must be done to select the appropriate additional therapy.[2,3]

Definitions of TNM

The American Joint Committee on Cancer has designated staging by TNM classification to define lip and oral cavity cancer.[4]

Treatment Option Overview

Depending on the site and extent of the primary tumor and the status of the lymph nodes, some general considerations for the treatment of lip and oral cavity cancer include the following:[1,2,3,4,5]

Surgery alone.

Radiation therapy alone.

A combination of the above.

For lesions of the oral cavity, surgery must adequately encompass all of the gross as well as the presumed microscopic extent of the disease. If regional nodes are positive, cervical node dissection is usually done in continuity. With modern approaches, the surgeon can successfully ablate large posterior oral cavity tumors and with reconstructive methods can achieve satisfactory functional results. Prosthodontic rehabilitation is important, particularly in early-stage cancers, to assure the best quality of life.

Radiation therapy for lip and oral cavity cancers can be administered by external-beam radiation therapy (EBRT) or interstitial implantation alone, but for many sites the use of both modalities produces better control and functional results. Small superficial cancers can be very successfully treated by local implantation using any one of several radioactive sources, by intraoral cone radiation therapy, or by electrons. Larger lesions are frequently managed using EBRT to include the primary site and regional lymph nodes, even if they are not clinically involved. Supplementation with interstitial radiation sources may be necessary to achieve adequate doses to large primary tumors and/or bulky nodal metastases. A review of published clinical results of radical radiation therapy for head and neck cancer suggests a significant loss of local control when the administration of radiation therapy was prolonged; therefore, lengthening of standard treatment schedules should be avoided whenever possible.[6,7]

Early cancers (stage I and stage II) of the lip, floor of the mouth, and retromolar trigone are highly curable by surgery or radiation therapy. The choice of treatment is dictated by the anticipated functional and cosmetic results. Availability of the particular expertise required of the surgeon or radiation oncologist for the individual patient is also a factor in treatment choice.

Advanced cancers (stage III and stage IV) of the lip, floor of the mouth, and retromolar trigone represent a wide spectrum of challenges for the surgeon and radiation oncologists. Most patients with stage III or stage IV tumors are candidates for treatment by a combination of surgery and radiation therapy. Patients with small T3 lesions and no regional lymph nodes, and no distant metastases or patients who have no lymph nodes larger than 2 cm in diameter, for whom treatment by radiation therapy alone or surgery alone might be appropriate, are the exceptions. Because local recurrence and/or distant metastases are common in this group of patients, they should be considered for clinical trials that are evaluating the following:

The potential role of radiation modifiers to improve local control or decrease morbidity.

The role of combinations of chemotherapy with surgery and/or radiation therapy both to improve local control and to decrease the frequency of distant metastases.

Early cancers of the buccal mucosa are equally curable by radiation therapy or by adequate excision. Patient factors and local expertise influence the choice of treatment. Larger cancers require composite resection with reconstruction of the defect by pedicle flaps.

Early lesions (T1 and T2) of the anterior tongue may be managed by surgery or by radiation therapy alone. Both modalities produce 70% to 85% cure rates in early lesions. Moderate excisions of tongue, even hemiglossectomy, can often result in little speech disability provided the wound closure is such that the tongue is not bound down. If, however, the resection is more extensive, problems may include aspiration of liquids and solids and difficulty in swallowing in addition to speech difficulties. Occasionally, patients with tumor of the tongue require almost total glossectomy. Large lesions generally require combined surgical and radiation treatment. The control rates for larger lesions are about 30% to 40%. According to clinical and radiological evidence of involvement, cancers of the lower gingiva that are exophytic and amenable to adequate local excision may be excised to include portions of bone. More advanced lesions require segmental bone resection, hemimandibulectomy, or maxillectomy, depending on the extent of the lesion and its location.

Early lesions of the upper gingiva or hard palate without bone involvement can be treated with equal effectiveness by surgery or by radiation therapy alone. Advanced infiltrative and ulcerating lesions should be treated by a combination of radiation therapy and surgery. Most primary cancers of the hard palate are of minor salivary gland origin. Primary squamous cell carcinoma of the hard palate is uncommon, and these tumors generally represent invasion of squamous cell carcinoma arising on the upper gingiva, which is much more common. Management of squamous cell carcinoma of the upper gingiva and hard palate are usually considered together. Surgical treatment of cancer of the hard palate usually requires excision of underlying bone producing an opening into the antrum. This defect can be filled and covered with a dental prosthesis, which is a maneuver that restores satisfactory swallowing and speech.

Patients who smoke while on radiation therapy appear to have lower response rates and shorter survival durations than those who do not;[8] therefore, patients should be counseled to stop smoking before beginning radiation therapy. Dental status evaluation should be performed prior to therapy to prevent late sequelae.

Surgery alone for patients with lesions smaller than 1 cm in diameter, if the commissure is not involved.

2.

Radiation therapy, including brachytherapy, should be considered to treat lesions smaller than 1 cm in diameter, if the commissure is involved.

3.

Surgical excision with a split-thickness skin graft or radiation therapy is used to treat larger T1 lesions.

Small Lesions of the Floor of the Mouth

Standard treatment options:

1.

Surgery for patients with T1 lesions.

2.

Radiation therapy is used to treat T1 lesions.

3.

Excision alone is generally adequate to treat lesions smaller than 0.5 cm, if there is a margin of normal mucosa between the lesion and the gingiva.

4.

Surgery is often used, if the lesion is attached to the periosteum.

5.

Radiation therapy is often used, if the lesion encroaches on the tongue.

Small Lesions of the Lower Gingiva

Standard treatment options:

1.

Intraoral resection with or without a rim resection of bone and repair with a split-thickness skin graft are used to treat small lesions.

2.

Radiation therapy may be used for small lesions, but results are generally better after surgery alone.

Small Tumors of the Retromolar Trigone

Standard treatment options:

1.

Limited resection of the mandible is performed for early lesions without detectable bone invasion.

2.

Radiation therapy may be used initially, if limited resection is not feasible, with surgery reserved for radiation failure.

Small Lesions of the Upper Gingiva and Hard Palate

Standard treatment options:

1.

Surgical resection is used to treat most small lesions.

2.

Postoperative radiation therapy may be used, if appropriate.

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I lip and oral cavity cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Stage II Lip and Oral Cavity Cancer

Surgery and/or radiation therapy may be used, depending on the exact site.[1]

Small Lesions of the Lip

Standard treatment options:

1.

Surgery is used for patients with smaller T2 lesions on the lower lip, if simple closure produces an acceptable cosmetic result.

2.

Radiation therapy, which may include external-beam and/or interstitial techniques, as appropriate, has the advantage of producing a relatively better functional and cosmetic result with intact skin and muscle innervation, if a reconstructive surgical procedure is required.

Small Anterior Tongue Lesions

Standard treatment options:

1.

Radiation therapy is usually selected for patients with T2 lesions that have minimal infiltration to preserve speech and swallowing. [2]

2.

Surgery is reserved for patients for whom radiation treatment failed.[2]

3.

Neck dissection may be considered when primary brachytherapy is used.[2]

4.

Surgery, radiation therapy, or a combination of both are used for deeply infiltrative lesions.

Small Lesions of the Buccal Mucosa

Standard treatment options:

1.

Radiation therapy is the usual treatment for patients with small T2 lesions (?3 cm).

2.

Surgery, radiation therapy, or a combination of these are used, if indicated to treat large T2 lesions (>3 cm). Radiation therapy is often used, if the lesion involves the commissure. Surgery is often used, if tumor invades the mandible or maxilla.

Small Lesions of the Floor of the Mouth

Standard treatment options:

1.

Surgery is often used for patients with small T2 lesions (?3 cm), if the lesion is attached to the periosteum.

2.

Radiation therapy is often used to treat patients with small T2 lesions (?3 cm), if the lesion encroaches on the tongue.

3.

Surgery and radiation therapy are alternative methods of treatment for patients with large T2 lesions (>3 cm), the choice of which depends primarily on the expected extent of disability from surgery.

4.

External-beam radiation therapy with or without interstitial radiation therapy should be considered postoperatively for larger lesions.

Small Lesions of the Lower Gingiva

Standard treatment options:

1.

Intraoral resection with or without a rim resection of bone and repair with a split-thickness skin graft are used to treat patients with small lesions.

2.

Radiation therapy may be used to treat patients with small lesions, but results are generally better after surgery alone.

Small Tumors of the Retromolar Trigone

Standard treatment options:

1.

Limited resection of the mandible is performed to treat patients with early lesions that are without detectable bone invasion.

2.

Radiation therapy may be used initially, if limited resection is not feasible.

3.

Surgery is reserved for radiation failure.

Small Lesions of the Upper Gingiva and Hard Palate

Standard treatment options:

Surgical resection with postoperative radiation therapy, as appropriate, is used to treat most lesions. A small study showed that radiation therapy may be used effectively as the sole treatment modality.[3]

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II lip and oral cavity cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Stage III Lip and Oral Cavity Cancer

Surgery and/or radiation therapy are used, depending on the exact tumor site.[1,2] Neoadjuvant chemotherapy, as given in clinical trials, has been used to shrink tumors and render them more definitively treatable with either surgery or radiation. Neoadjuvant chemotherapy is given prior to the other modalities, as opposed to standard adjuvant chemotherapy, which is given after or during definitive therapy with radiation or after surgery. Many drug combinations have been used as neoadjuvant chemotherapy.[3,4,5,6] Randomized, prospective trials, however, have yet to demonstrate a benefit in either disease-free survival or overall survival for patients receiving neoadjuvant chemotherapy.[7]

Advanced Lesions of the Lip

These lesions, including those involving bone, nerves, and lymph nodes, generally require a combination of surgery and radiation therapy.

Standard treatment options:

1.

Surgery using a variety of surgical approaches, the choice of which is dependent on the size and location of the lesion and the needs for reconstruction.

2.

Radiation therapy using a variety of therapy techniques, including external-beam radiation therapy (EBRT) with or without brachytherapy, the choice of which is dictated by the size and location of the lesion.

Treatment options under clinical evaluation:

1.

Clinical trials for advanced tumors evaluating the use of chemotherapy preoperatively, before radiation therapy, as adjuvant therapy after surgery, or as part of combined modality therapy are appropriate.[3,4,5,6,8,9,10]

EBRT with or without interstitial implant is used to treat minimally infiltrative lesions.

2.

Surgery with postoperative radiation therapy is used to treat deeply infiltrative lesions.[2]

Advanced Lesions of the Buccal Mucosa

Standard treatment options:

1.

Radical surgical resection alone.

2.

Radiation therapy alone.

3.

Surgical resection plus radiation therapy, generally postoperative.

Treatment options under clinical evaluation:

Clinical trials for advanced tumors evaluating the use of chemotherapy preoperatively, before radiation therapy, as adjuvant therapy after surgery, or as part of combined modality therapy are appropriate.[3,4,5,6,8,9,10,12]

Clinical trials for advanced tumors evaluating the use of chemotherapy preoperatively, before radiation therapy, as adjuvant therapy after surgery, or as part of combined modality therapy are appropriate.[3,4,5,6,8,9,10,12]

Combined radiation therapy and radical resection or radical resection alone are used to treat extensive lesions with moderate bone destruction and/or nodal metastases; radiation therapy may be administered either preoperatively or postoperatively.

Advanced Lesions of the Retromolar Trigone

Standard treatment options:

Surgical composite resection that may be followed by postoperative radiation therapy.

Treatment options under clinical evaluation:

1.

Clinical trials for advanced tumors evaluating the use of chemotherapy preoperatively, before radiation therapy, as adjuvant therapy after surgery, or as part of combined modality therapy are appropriate.[3,4,5,6,8,9,10,12]

Patients with advanced lesions should have elective lymph node radiation therapy or node dissection. The risk of metastases to lymph nodes is increased by high-grade histology, large lesions, spread to involve the wet mucosa of the lip or the buccal mucosa in patients with recurrent disease, and invasion of muscle (i.e., orbicularis oris).

Standard treatment options:

1.

Radiation therapy alone or neck dissection:

N1 (0–2 cm).

N2b or N3; all nodes smaller than 2 cm. (A combined surgical and radiation therapy approach should also be considered.)

2.

Radiation therapy and neck dissection:

N1 (2–3 cm), N2a, N3.

3.

Surgery followed by radiation therapy, indications for which are as follows:

Multiple positive nodes.

Contralateral subclinical metastases.

Invasion of tumor through the capsule of the lymph node.

N2b or N3 (one or more nodes in each side of the neck, as appropriate, >2 cm).

4.

Radiation therapy prior to surgery:

Large fixed nodes.

Treatment options under clinical evaluation (all stage III lesions):

Chemotherapy has been combined with radiation therapy in patients who have locally advanced disease that is surgically unresectable.[8,10,14,15]

A meta-analysis of 63 randomized, prospective trials published between 1965 and 1993 showed an 8% absolute survival advantage in the subset of patients receiving concomitant chemotherapy and radiation therapy.[16][Level of evidence: 2A] Patients receiving adjuvant or neoadjuvant chemotherapy had no survival advantage. Cost, quality of life, and morbidity data were not available; no standard regimen existed; and the trials were felt to be too heterogenous to provide definitive recommendations. The results of 18 ongoing trials may further clarify the role of concomitant chemotherapy and radiation therapy in the management of oral cavity cancer.

The best chemotherapy to use and the appropriate way to integrate the two modalities is still unresolved.[17]

Similar approaches in the patient with resectable disease, in whom resection would lead to a major functional deficit, are also being explored in randomized trials but cannot be recommended at this time as standard.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III lip and oral cavity cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Stage IV Lip and Oral Cavity Cancer

Randomized, prospective trials have yet to demonstrate a benefit in either disease-free survival or overall survival for patients receiving neoadjuvant chemotherapy.[1] The use of isotretinoin (13-cis-retinoic acid) daily for 1 year to prevent development of second upper aerodigestive tract primaries is under clinical evaluation.[2]

Advanced Lesions of the Lip

These lesions, including those involving bone, nerves, and lymph nodes, generally require a combination of surgery and radiation therapy.

Standard treatment options:

1.

Surgery using a variety of surgical approaches, the choice of which is dependent on the size and location of the lesion and the needs for reconstruction. Treatment of both sides of the neck is indicated for selected patients.

2.

Radiation therapy using a variety of therapy techniques, including external-beam radiation therapy (EBRT) with or without brachytherapy, the choice of which is dictated by the size and location of the lesion.

Patients with advanced lesions should have elective lymph node radiation therapy or node dissection. The risk of metastases to lymph nodes is increased by high-grade histology, large lesions, spread involving the wet mucosa of the lip or the buccal mucosa in patients with recurrent disease, and invasion of muscle (orbicularis oris).

Standard treatment options:

1.

Radiation therapy alone or neck dissection:

N1 (0–2 cm).

N2b or N3; all nodes smaller than 2 cm. (A combined surgical and radiation therapy approach should also be considered.)

2.

Radiation therapy and neck dissection:

N1 (2–3 cm), N2a, N3.

3.

Surgery followed by radiation therapy is indicated for the following:

Multiple positive nodes.

Contralateral subclinical metastases.

Invasion of tumor through the capsule of the lymph node.

N2b or N3 (one or more nodes in each side of the neck, as appropriate, >2 cm).

4.

Radiation therapy prior to surgery:

Large fixed nodes.

Treatment options under clinical evaluation (all stage IV lesions):

1.

Chemotherapy has been combined with radiation therapy in patients who have locally advanced disease that is surgically unresectable.[6,7,8,9]

A meta-analysis of 63 randomized, prospective trials published between 1965 and 1993 showed an 8% absolute survival advantage in the subset of patients receiving concomitant chemotherapy and radiation therapy.[10][Level of evidence: 2A] Patients receiving adjuvant or neoadjuvant chemotherapy had no survival advantage. Cost, quality of life, and morbidity data were not available; no standard regimen existed; and the trials were felt to be too heterogenous to provide definitive recommendations. The results of 18 ongoing trials may further clarify the role of concomitant chemotherapy and radiation therapy in the management of oral cavity cancer.

The best chemotherapy to use and the appropriate way to integrate the two modalities is still unresolved.[11]

Similar approaches in the patient with resectable disease, in whom resection would lead to a major functional deficit, are also being explored in randomized trials but cannot be recommended at this time as standard.

2.

Clinical trials for advanced tumors evaluating the use of chemotherapy preoperatively, before radiation therapy, or as adjuvant therapy after surgery are appropriate.[6,12,13,14,15,16,17,18,19]

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IV lip and oral cavity cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Recurrent Lip and Oral Cavity Cancer

For lesions of the lip, anterior tongue, buccal mucosa, floor of the mouth, retromolar trigone, upper gingiva, and hard palate, treatment will be dictated by the location and size of the recurrent lesion as well as prior treatment.[1,2]

Standard treatment options:

1.

Surgery is the preferred treatment, if radiation therapy was used initially.[3]

2.

Surgery,[3] radiation therapy, or a combination of these may be considered for treatment, if surgery was used to treat the lesion initially.

3.

Although chemotherapy has been shown to induce responses, no increase in survival has been demonstrated.[4]

Treatment options under clinical evaluation:

Clinical trials evaluating new chemotherapy drugs, chemotherapy and re-irradiation, or hyperthermia should be considered because surgical salvage after primary treatment by radiation therapy and radiation therapy after primary surgery give poor results.[5,6]

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent lip and oral cavity cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Changes to This Summary (02 / 28 / 2014)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

General Information About Lip and Oral Cavity Cancer

Editorial changes were made to this section.

This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of lip and oral cavity cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

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Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

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